Referring Doctors

Download our referral form or fill up the form online.


Introducing (required)

Phone (home) (required)



Referred by Dr. (required)

Office phone

Limited Exam

Area of Concern

Pocket reductionRecession/ minimum attachedtissue/ soft tissue graftingCrown lengtheningUneven gingival displaygummy smileCanine exposureExtractionFrenectomyOral pathology/ biopsyOther

If other, please type here

Full Mouth Periodontal Evaluation

Last hygiene date

Dental Implant Treatment

Teeth #

Precision Periodontics to send patient back with
Healing abutmentCustom abutmentProvisional crown

Bone graftingPeri-implant disease

Pre-Orthodontic Periodontal Exam

Full mouthMaxillary archMandibular arch

Radiographs available

FMX Date:
PA Date:
BWX Date:

Comments/ Relevant Medical Conditions/Restorative Plan: